HospitalInspections.org

Based on observation during the survey walk-through, the facility lacks a continuous fire resistant barrier between healthcare and other occupancies. This deficient practice could affect the safe egress of all patients, staff and visitors within a non conforming occupancy compartment if a fire incident occurs in the adjacent compartment.

The finding is:

On 11/14/2016 at 2:20pm while accompanied by the DSS, the surveyor observed a wall between the 1972 building and the 2000 addition on the 1st floor. This wall is located between the 1972 and 2000 editions adjacent to the Chapel and contains a pair of cross corridor doors. This wall was indicated to be of 2-hour rated construction but was observed to only function as a smoke barrier due to the location of the wall with respect to the requirements of a continuous barrier. The wall did not comply with 8.3.1.2. The wall was not continuous to the floor above or to an outside wall on the 1st floor.

Based on observation during the survey walk-through, the facility lacks a continuous fire resistant barrier between different non healthcare occupancies. This deficient practice could affect the safe egress of all patients, staff and visitors within a non conforming occupancy compartment if a fire incident occurs in the adjacent compartment.

Findings include:

A. On 11/15/2016 at 10:20am while accompanied by the DSS, the surveyor observed a wall between the 1972 addition and the 1956 addition. This wall did not provide a continuous required 2-hour fire resistant barrier. The wall did not comply with 8.3.1.2 due to the following:

1. 2nd floor cross corridor door at 2-hour barrier across from Command Center was not self closing and, therefore, did not remain in the closed and latched position.

2. 1st floor door at 2-hour barrier from mechanical room to the 1956 storage area was not self closing and, therefore, did not remain in the closed and latched position.

Based on observation during the survey walk-through, a smoke compartment contains one means of egress. This deficient practice could affect the safe egress of all patients, staff and visitors within that smoke compartment if a fire incident occurs in the adjacent compartment.

The finding is:

A. On 11/14/16 at 2:55pm while accompanied by the DSS it was observed that the second floor of the 1972 building addition does not comply with 39.2.5.2 and 39.2.5.3.1 and 7.5.1.5 for dead ends and common path of travel due to the following:

1. South Stair from the 2nd floor of the 1972 building is no longer used as an exit which leaves exiting in one direction only through the adjacent compartment. Thus a dead end corridor condition of excessive length is produced which does not comply 39.2.5.2.

Based on observation during the survey walk-through, remotely located means of egress are not provided. This deficient practice could affect all patients, staff and visitors within the area of the facility, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

A. On 11/14/16 at 2:45pm while accompanied by the DSS it was observed that the 2nd floor of the 1972 building addition does not comply with 39.2.4.1 and 7.5.1.3. for remoteness of exits due to the following:

1. South Stair from the 2nd floor of the 1972 building is no longer used as an exit which leaves two stairs remaining, both within the same corridor one located adjacent to the elevator the other adjacent to computer lab. This layout does not comply with 7.5.1.3.1.

Based on observation during the survey walk-thru, means of egress are not maintained to provide a protected and unimpeded path to exits. This deficient practice could affect patients, staff and visitors if a failure to provide required paths compromises access and level of safety for occupants.

Findings include:

A. On 11/15/16 at 10:00am while in the company of the DSS it was observed that exit discharges do not comply with 7.7.2 for not more than 50% of the required number of exits allowed to discharge interior. Surveyor observed 3 exit stairs from the 1972 2nd floor. One stair (East stair) discharges to an exit passageway on the 1st floor adjacent to Surgery and Recovery. The remaining stairs do not comply due to the following:

1. The 2nd floor south stair is no longer used as an exit stair. The stair discharges into an employee lounge located on the 1st floor.

2. The 2nd floor landing inside the south stair is used for storage.

3. The discharge door for the West stair on the 1st floor does not open in the direction of egress. The door does not comply with 7.2.1.4.2 and 7.7.4 for a component of the exit discharge.

4. The 1st floor means of egress corridor door for the West stair leading to the main corridor adjacent to the elevator, does not open in the direction of egress. The door does not comply with 7.2.1.4.2 and 7.7.4 for a component of the exit discharge.

B. On 11/14/2016 at 1:10pm while accompanied by the DSS the designated exterior exit path adjacent to the mechanical room discharge does not comply with 7.1.8 and 7.2.2.4.5.3 for the requirements of a continuous curb on the open of a guard rail. Location observed: the exterior egress path along side of the areaway for the mechanical room discharge. The areaway is greater than 30 inches below grade. The exterior guard railing lacks a continuous curb in order to protect a person from slipping below the railing.

Based on observation during the survey walk-through, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

Findings include:

A. On 11/14/16 at 2:15pm while accompanied by the DSS it was observed that only one path of exit access was identified by exit signage which does not comply with 19.2.5.4. Example locations observed include the following:

1. 2nd floor corridor located adjacent to Command Center, and other offices leading toward the Infection Control office.

2. 2nd floor corridor located adjacent to conference rooms and outpatient sleep study leading to the South stair.

3. 1st floor Surgery suite west end pair of cross corridor auto opening doors leading to the corridor outside of surgery waiting.

4. 1st floor Imaging area pair of cross corridor doors leading from Imaging to the main corridor adjacent to the cashier office.

5. 1st floor corridor leading from the 1972 addition to the 2000 addition.

B. On 11/15/2016 at 9:50am while accompanied by the DSS a wall hung exit sign was observed which directed exiting to a mechanical room at the end of a corridor. Location observed: 1st floor discharge from West stair.

Based on observation during the survey walk-through, not all hazardous areas are separated from the remainder of the building. These deficiencies could affect all patients adjacent to the areas, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into adjacent areas and the building's exit access corridors.

Findings include:

A. On 11/14/2016 at 2:10pm while accompanied by the DSS a storage alcove housing a battery cabinet for the CT room was observed open to the means of egress. This condition does not comply with the separation requirements of hazardous areas from adjacent locations to comply with 8.4. Location observed: 1st floor Imaging suite, battery alcove adjacent to the CT control room and Radiology room # 1.

B. On 11/14/2016 at 1:40pm while accompanied by the DSS the Gift shop was observed to contain combustible materials in a quantity deemed hazardous. A door wedge was observed holding the entry door of the Gift Shop open to a means of egress corridor. This condition does not comply with the separation requirements of hazardous areas from adjacent locations to comply with 8.4.

Based on document, review evidence was not provided as to the installation / maintenance of the kitchen hood suppression system signaling components. This deficient practice could result in the delayed response by emergency forces during a fire event, which may affect patients, staff and visitors.
The finding is:
On 11/15/16 at 9:00am in the company of the DSS, the surveyor finds the lack of documentation as to the connection and or testing of the connection between the kitchen hood suppression system and the building fire alarm system. NFPA 96, 2011, 10.6.2

Based on observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with Code requirements. This deficiency could affect any patients, staff, or visitors in the immediate area by causing the smoke detector to fail to operate under fire conditions.

The finding is:

On 11/15/2016 at 9:45am, while accompanied by the DSS, a doctor's sleep room was observed which lacked a smoke alarm along with a visual/audible device to comply with NFPA 72.
Location observed: 1st floor 1972 addition, adjacent to the Chapel.

Based on direct observation, the facility failed to install complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

Findings include:

A. On 11/14/16 at 2:15pm in the company of the DSS, the surveyor observed the lack of fire sprinkler protection for the alcove containing the battery cabinet for the UPS system for the CAT Scan equipment in radiology. NFPA 13, 2010, 8.1.1.

B. On 11/15/16 at 10:15am in the company of the DSS, the surveyor observed the lack of fire sprinkler protection for the hydraulic elevator machine room. NFPA 13, 2010, 8.1.1.

Based on observation, the facility failed to provide adequate protection of spaces open to the corridor. This condition could affect patients, staff and visitors if the means of egress is compromised due to the lack of protection for early notification of fire or smoke.

The finding is:

On 11/15/16 at 10:10am while accompanied by the DSS, a patient dressing alcove was observed open to a means of egress corridor. The Life Safety floor plans did not indicate that the area was a suite. The location observed is the Imaging patient gowning room which does not comply with 19.3.6.1(1)c.

Based on observation during the walk-through and staff interview not all portions of the facility's heating, air conditioning and ventilation system are installed to maintain a safe means of egress. This deficient practice would affect all patients, visitors and staff from using a means of egress corridor during a fire/smoke emergency should smoke transfer to the area.

The finding is:

On 11/15/2016 at 9:15am while accompanied by the DSS through wall louvers were observed at a required 2-hour fire resistant rated occupancy separation wall. The DSS informed the surveyor that the louvers lacked damper installations. Therefore the duct penetrations at the barrier wall lack a properly installed combination fire/smoke damper which does not comply with 8.3.5.7, 9.2.1 and NFPA 90A. Location observed: 1st floor East wall of the Chapel.

Based on observation during document review locations of current exits is not provided. This deficiency could result in a delayed evacuation from the smoke compartment of fire origin to an area of refuge during a fire emergency. This condition could affect patients, staff and visitors.

The finding is:

On 11/15/2016 during review of the facility's written Fire Plan, and discussion with the DSS, it was determined that the written Fire Plan did not coincide with the egress floor plans attached to it. The floor plans indicate exiting to the South stair from the second floor area. This stair is currently not available. The written Plan is not maintained to provide for current conditions as required by 19.7.1.1.